It’s summer, which means that CMS has released another draft regulation that is sure to send shockwaves through the industry. While this draft is not final — the draft was released in the Summer, comments will be accepted from stakeholders in the months following, then a final version of the rule will be announced in the Fall, as per usual — we feel that it’s important to go through the prospective changes it lays out, as these alterations indicate CMS’ priorities for the coming year.
While there are numerous changes throughout the draft regulation, we want to focus on a few specific areas that are of significant interest. The first area we’d like to cover is some exciting news for emergency physicians and patients. In this current draft, CMS has announced the cancellation of the Appropriate Use Criteria (AUC) program.
For context, the AUC initiative would have mandated healthcare practitioners to utilize clinical decision support tools and consult ‘appropriate use criteria’ before requesting advanced imaging procedures for Medicare beneficiaries. Though there was an exemption in place for urgent medical situations, there were reports that some emergency doctors had trouble invoking this exemption. This, in turn, led many to worry that emergency physicians might still be required to follow AUC even in suspected or confirmed medical emergencies, consuming valuable time unnecessarily.
Although the draft as it exists today leaves the door open to reevaluate and reimplement this program, the draft’s proposed cancellation of AUC does not lay out a timeframe for reimplementation. As such, it appears that the AUC program should not be a concern for healthcare professionals for the foreseeable future, so long as this provision remains in the final draft.
Next, there is more good news. Previous rules had discussed changing the definition of what constituted ‘physician involvement’ in patient care provided by both a physician and an advanced practice clinician (APC). This is an important distinction, as Medicare pays a higher rate if a physician is ‘involved’ than if an APC provides a substantive portion of the care. This is a comparable policy to many insurance companies.
As it stands currently, a physician is considered to be ‘involved’ if they perform the history, physical, or the medical decision making for a patient. However, CMS had previously indicated that they intended to change the definition of ‘involved,’ instead determining ‘involvement’ after seeing if the physician performed the substantive portion of care based on the time they spent with the patient, among other factors.
While this policy may make sense on paper, in the real world, measuring the amount of time spent on a single patient is near impossible. For example, in emergency medicine, where physicians are continuously caring for multiple patients at once, it is difficult and unnecessarily time-consuming to make a distinction between where one patient’s care ends and another begins.
In the current draft, this ‘involved’ definition change is being delayed. That said, much like the ‘cancellation’ of the AUC initiative, this proposed delay gives CMS the option of reintroducing the idea further down the line. Still, their decision to delay the change in the first place indicates that they are listening to physician complaints about their many proposed changes and responding accordingly.
Along with the good news, of course, comes bad news. CMS has announced that, if this rule is enacted unchanged, there will be a 3.36% decreased reimbursement for most specialties based on a decreased conversion factor. As a result, CMS estimates that emergency medicine will see a decrease in reimbursement of 5.4%, while wound care and urgent care will see a 2.4% decrease.
At this stage, this rule is simply a proposal, and CMS is currently accepting comments as to how the rule can be changed. While there are many things to like about this rule, there are others that require additional changes and scrutiny. We will keep you updated as the rule changes as we approach a final rule later this year.